World Health Organization urges more HIV testing by non-medical staff, outside of clinical settings, targeted to those who need it the most

In addition to recommending that routine HIV testing in medical
settings be expanded to reach new groups of patients, the World Health
Organization’s new guidance on HIV testing also recommends the delivery of HIV
testing by non-medical ‘lay providers’, often in community settings. The
guidance urges planners to make careful, strategic choices about which HIV
testing interventions will be best able to reach individuals with undiagnosed
HIV. New approaches may be needed to reach key populations.

Improvements in HIV testing services are needed if the
global targets of 90-90-90 are to be achieved. But many countries are lagging
further behind on the objective of diagnosing 90% of people living with HIV than
for the other two targets.

“The first 90 – diagnosis of HIV – is essential to the
second 90 – initiation of ART among people with HIV – and the ultimate outcome
of the third 90 – viral load suppression among people on ART,” the guidance
says.

Due to HIV testing’s role within the treatment cascade, linkage
to care is seen as an essential component of HIV testing services. Suggested
practices include offering immediate antiretroviral therapy to people testing at home, integration
of HIV testing and treatment services, transport vouchers, support from peers
or lay providers, and case-management approaches. Moreover, people receiving an
HIV-negative result may need linkage to HIV prevention services.

Counselling is still seen as a key component but providers
need to do more than counsel and test. Hence the shift in terminology from
voluntary testing and counselling (VTC) and HIV testing and counselling (HTC)
to the current preferred term: HIV Testing Services (HTS).

For the first time, WHO recommends a larger role for lay providers
in HIV testing. Lay providers are people who have been trained to deliver
specific health services but do not have a formal medical education. This is in
part a response to workforce and financial shortages. But it also allows HIV
testing services to be provided differently, by people who are peers of those
testing. They may be able to offer culturally competent, non-judgemental and
respectful support which can improve the uptake of HIV testing in key
populations such as men who have sex with men, sex workers and people who
inject drugs.

“Expanding testing is probably the single most powerful game
changer.” Luiz Loures, deputy executive director of UNAIDS

The guidelines recommend that lay providers be carefully
selected, trained and appropriately remunerated. Many countries will need to adjust their
national policies to allow lay providers to be involved in all stages of HIV
testing, including collecting the specimens and delivering the result.

The guidance reviews a range of ways of providing HIV
testing. This includes testing in health facilities (standalone VCT or
provider-initiated testing when the client is seeking healthcare for another
reason), as well as a range of community-based HIV testing services (including
outreach, door to door testing in homes, national campaigns, multi-disease
campaigns and workplace testing). WHO coins a new term, ‘test for triage’ to
describe community-testing services which will systematically refer to other
services for confirmation of what appear to be HIV-positive results.

Selecting the most appropriate interventions to provide
requires careful assessment of the prevalence of HIV in different social
groups, current uptake of HIV testing services, the available resources,
cost-effectiveness and the preferences of people needing testing.

Rachel Baggaley of WHO noted that there is frequently a
mismatch between the populations served by existing testing services and the
populations with undiagnosed HIV. Due to the success of integrating HIV testing
into antenatal and reproductive health services, in every region of the world a
majority of those taking an HIV test are women. However in every region apart
from Africa, a majority of those testing positive are men.

She re-iterated that the objective of HIV testing services
is to identify and test people who are unaware of their HIV infection, and to
do so as early in the course of their infection as possible. The HIV testing
approaches which should be selected must be those which result in the highest
proportion of HIV-positive diagnoses in priority populations.

For example, outreach to key populations may raise testing
rates in people who feel excluded from mainstream health services. Programmes
which encourage the sexual partners of pregnant women to come in for testing
may help raise testing rates in men. Routine testing in health facilities can
reach substantial numbers of people at a low cost and is appropriate where the
prevalence of undiagnosed HIV remains high.

Cheryl Johnson of WHO outlined the emerging evidence on self-testing (home testing) but said that the public health response is lagging
behind public demand. HIV tests designed for self-testing are already legal and commercially available
in several countries, while HIV tests intended for use by health professionals are already being used by individuals in an unregulated
way elsewhere. The most appropriate ways to deliver and distribute self-testing
kits have not yet been defined.

“Expanding testing is probably the single most powerful game
changer,” Luiz Loures, deputy executive director of UNAIDS said. “Self-testing
is the fundamental direction that we should take – knowing your status is a
fundamental right. We need to find a way to bring testing closer to the people
who are discriminated against by health systems.”

NAM's coverage of the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) has been made possible thanks to support from Bristol-Myers Squibb, Gilead, Merck & Co., Inc., and ViiV Healthcare.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap

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checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member
of your healthcare team for advice tailored to your situation.